Provider Demographics
NPI:1003952847
Name:MIKEWORTH, JACK L (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:MIKEWORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 LEIGHTON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3228
Mailing Address - Country:US
Mailing Address - Phone:817-557-9523
Mailing Address - Fax:866-807-8992
Practice Address - Street 1:2200 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-6066
Practice Address - Country:US
Practice Address - Phone:817-926-4693
Practice Address - Fax:817-920-9625
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor